22618 HWY 99 STE 109 (3)_RedactedS-r /oq
FIRE PR NTION
SNOxOlY SH CO.
>. Serving Brier, Edmonds, and 12425 Meridian Ave S
INSP ION REPORT
Mountlake Terrace Everett, WA 98208
ONDS
FIRE
BRIER
IER
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Phone (425) 551-1200
❑ MOUNTLAKE TERRACE,
DISTR
T www.FireDistrictl.org Fax (425) SS1-1272
❑ UNINCORPORATED
FREQUENCY
STATION & SHIFT
LOCATION:
22618 Highway 99 Suite 109 98026
2016*
20-B
BUSINESS NAME:
Highland Pharmacy PHONE: 4256738533
SCHEDULED
DATE DUE ►Mar 2016
MAILING
FIR 543
ADDRESS:
22618 Highway 99, Suite 109, Edmonds, WA 98026
BUSINESS OWNER:
HOME PHONE:
EMERGENCY-1:
HOME PHONE: �� -110
..Secal�g�ae I !vt , r/ YQ K YUN� 4257442
CURRENT
KEY ACCESS 2:
HOME PHONE: "'"
CITY YES NO
EMAIL:
BUSINESS
LICENSE
PERSON CONTACTED: •
INITIAL INSPECTION 15ATE
NAME OF INSPECTOR:
FIRE SYSTEMS:
FE 3/14 SlZolb
nnta I act Caniirari•
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
2
2
3
3
4.
4
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5
6
6
I AGREE TO.CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1 st RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE_: Y
DATE DUE:
GRANTEDTO:
DATE DUE:
CITED:
PERSON -
PERSON
CONTACTED:
CONTACTED:
PERSON •'
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CONTACTED:
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INSPECTOR: Ud,I�ST�nI
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DATE: q "Lb"I �
DATE:
DATE:
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VIOLATIONS:" :;
PRE -CITATION
CITATION ISSUED
1�
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LETTER SENT
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
RETURN RECEIPT
3
7
3
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RECEIVED
6
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DISPOSITION:
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4
8
4
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DATE:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
8
SNO]
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LOCATION:
BUSINESS NAME:
MAILING
ADDRESS:
BUSINESS OWNER:
EMERGENCY-1:
KEY ACCESS-2:
EMAIL:
Serving Brier; Edmonds, and 12425 Meridian Ave S
Mountlalle Terrace Everett WA 98208
www FireDistrictl. org
22815 Hi.qh+Amy 99 Suite 100 C18026
l lighlancl Pharmacy
Phone (425) 551-1200
Fax 425) 551-1272
PHONE: 42.5 i38562:
22518 1 ligh+tray 90, , Suitc 1M, Edamrx6i, WA OS02L
HOME PHONE:
I im, Scang lac HOME PHONE: 42,577N210
HOME PHONE:
PERSON CONTACTED:
NAME OF INSPECTOR: lV I L�A
FIRE SYS IEMS_ FE -27, 1 ,
FIRE PREVENTION
INSPECTION REPORT
9EDMONDS
[BRIER
❑ MOUNTLAKE TERRACE
❑ UNINCORPORATED
FREQUENCY STATION & SHIFT
2 Year 14 20-D
SCHEDULED oaf 2014
DATE DUE
UFIR443
CURRENT
CITY YES NO
BUSINESS
LICENSE )Q F-1
INITIAL INSPECTION DATE
- / - / LI
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1 k
1
2
2
3
3
4
4
5
5
' 6
6
7
7
1 AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
8
FIRE DEPARTMENT COPY
'~`_
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FIRE PREVENTION
Serving Brier; Edntortds
1. 425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
FIREMountlake Terrace, and
Everett, WA 98208
EDMONDS
BRIER
the Town of Wood vay --
DISTii' T
- Phone (425) 551-1200
❑ WOODWAY
• � ❑ M TERRACE
www.FireDistrictl.org org
Fax (425) SSI -I2 %2
INC-OR O
❑ UNINC-ORPORATED
FREQUENCY STATION & SHIFT
LOCATION: 22618 Hwy 99
11�89
730 20 R
r
BUSINESS NAME: Highland Pharmacy
PHONE: 4256738533
DATE DUE SCHEDULED► 03101112 r
MAILING 22618 Hwy 99 #109 a
UFIR ► 543 3 106
ADDRESS: Edmonds � 1� s
95026
BUSINESS OWNER: ",', .L.33 %Ie L-ee-
HOME PHONE: 4257704210
EMERGENCY-1: 'PB ,Ply in
I-tel en KiYY1
HOME PHONE: 42539uO4O3
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
'
BUSINESS
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
FIRE
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
1
2
2
3
3
4
4
5
5
6
6
0
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
•
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
I
INSPECTOR:
INSPECTOR:
,
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
a
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
a
4_
8
4
8
DATE:
DISPOSITION:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
a
FIRE DEPARTMENT COPY QQ
CITY OF EDMONDS
BUSINESS LICENSE APPLICATION —.COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE, BUSINESS'LICENSE DIVISION
lnc.189� 121 5T" AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
OFFICE USE ONLY
BL#
Customer#
S C
Year
s
SHD
I Date Paid
TR#
Fee Paid
Mailed Delete
INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle initial or name required of all
partles concerned. If no middle name, please Indicate by writing NMN. Sign and return application with fee. Please advise of
any change in status. New license- requited if business changes location or ownership. Notification to City of Edmonds required
U business closes.
BUSINESS NAME N (D1Y1 �13�1Qtiy p
BUSINESS ADDRESS
/ Street I
Suite No. Zip Code
MAILING ADDRESS _7 O�tM1^ Q15 G G ove—
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Street orPOBox Suite No. City, State and Jp.Code
BUSINESS PHONE NO. (� i 1 r�-j 3 —�h .33 WA STATE TAX 10 NO. (UBI NO.) 27 3--t•-7-
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BUSINESS E-MAIL '10'}'mail.op USINESS WE851TE
PROPERTY OWNER 00.9 Yt 0 a2-0-
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EMERGENCY NOTIFICATION (For Premise Access in Emergency):
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t 6 ► 3 0.2 —k- 74 .. .
Fist ame V MI
Phone No. �—
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Last Name FbtNamd Mi
Phone No.
NATURE OF BUSINESS bInaryyA!ni
NUMBER OF•EMPLOYEES _ SQUARE FOOTAGE OF BUSINESS SPACE
TYPE OF BUWNW - PLEASE CHECK.THE APPROPRIATE CATEGORY r !'f
O CONSTF2l1C71C�N• O FlNANCE; INSURANCE,ftEAL ES TATE• ' O LANDSCAPE, HORTICULTURAL O MANUFACTURING ONDN-PROFIT
,RETAIL• OrS!~CONDHAND .ERLER QSERVIC,ES OWHOLESALE• O.OTHER
AMUSEMENT DEVICES OWPREMISES?..CI YgS ` No . IF YES. TOTAL NUMBER
LIQUOR SOLD ON PREMISES?:• (3YES, NOGA(NBLIfiLG? OYES KNO CIGARETTES SOLD -ON PREMISES? O YES AO
FJ.AMMABLE OR HAZARDOUS MATERIALS USED OR STORED?:OYES NO IFYES; PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAYOF BUSINESS �Z -Z ZLO 10 BUSINESS HOURS MDi1 -Trt : Oq:3BN jp,,.DO. O•q,
DAYS OPEN O SUNDAY 1)'MONDAY gTUESDAY XWEDNESDAY gTHURSDAY )(FRIDAY j SATURD�A/Y
PARKING SPACES ON SITE: TOTAL _ I 0 D ACCESSIBLE FOR PERSONS WITH biSABIUTIES `F
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE
rTO1 PERSONS WITH DISABILITIES?. YES O NO
PREVIOUS BUSINESSUSEATTHISADDRESS P61r1n&!:!1 t
PROPRIETORSHIP
NAME .
last Flrst M!
ADDRESS
Street Apt No., Unit No. City, Slate and Zip Code
HOME PHONE NO. ( 1 DOL NO. (DRIVERS LICENSE NO.) OR OTHER 10 NO,
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 1
�' First MI
ADDRESS
Street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO.( ) DOL NO. (DRIVERS LICENSE NQ.) OR OTHER ID NO.
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2'
NAME .
Last .First M1.
ADDRESS '
Street Apt No., Unit 110. City, State and Zip Code
HOME PHONE NO.( 3 . DOL NO. (DRIVERS LICENSE NO.)'OR OTHERiD'NO:_
DATE OF BIRTH CITY AND STATE OF BRTH COUNTRY OF BIRTH
NAME'
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PHONE NO.(�.� 73 -
CORPORATE OFFICERS:
Last Name First Name MI Title
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LOCAL CONTACT
Last Name FlMt MI . Tide P e Nm� DOL No. (odVem Llm No.) or Other ID. o.
NAma Pdnted "Sigrtatuha t TiUe Date.
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•'°•` SIGNATURE
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COMMENTS
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" SIGNATURE? ,- '
POLICE DEPT.
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